Provider Demographics
NPI:1700880408
Name:CHEN, KURT Y (MD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:Y
Last Name:CHEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 WATERFORD DR SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-6463
Mailing Address - Country:US
Mailing Address - Phone:540-345-8159
Mailing Address - Fax:
Practice Address - Street 1:102 HIGHLAND AVE SE
Practice Address - Street 2:STE 104
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2255
Practice Address - Country:US
Practice Address - Phone:540-343-4423
Practice Address - Fax:540-343-0495
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050710174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA299660OtherMAMSI
VA010415675Medicaid
VA040006937OtherMEDICARE RR
VA6503241Medicaid
T61702OtherJOHN DEERE
VA010415667Medicaid
VA087653OtherANTHEM
VA299660OtherMAMSI
040000269Medicare ID - Type Unspecified
VA010415667Medicaid